Warning spurs caution on antidepressants in kids — (The Sacramento Bee)

SSRI Ed note: Girl, 14, given three antidepressants, then Effexor, commits suicide.

Original article no longer available

The Sacramento Bee

By Dorsey Griffith — Bee Medical Writer

Published 2:15 am PDT Monday, September 27, 2004

There’s a lot of hand-wringing going on in doctors’ offices now that the federal government is poised to throw a wrench into the widespread practice of prescribing antidepressants to children.

Since federal health officials released their warning that children and adolescents are more likely to commit suicide when prescribed the drugs, doctors are debating how to handle the estimated 3 percent to 5 percent of kids who suffer from depression.

Some medical professionals worry about a backlash that will keep parents and primary care doctors from considering drug treatment for children, even when such therapy is warranted.

But others welcome the new scrutiny by the Food and Drug Administration, saying doctors in general have been too quick to put children on psychiatric medication, and that the time is ripe for a more careful and integrated approach to helping kids who are feeling depressed.

“I think caution is the key,” said Dr. Joseph Sison, a Sacramento child psychiatrist and medical director for the Sacramento County Child and Family Mental Health Department. “We can’t just willy-nilly be prescribing these medications without thinking about the possible side effects. You need to fully diagnose the kid, know the risks, watch them carefully and see them frequently.”

An FDA advisory committee this month recommended adding a “black box” warning to the labels of antidepressants. The decision came after committee members determined that, except for Prozac, industry studies did not prove the drugs effective for kids with depression and that they resulted in an increased risk of suicidal thinking and behavior in children and adolescents.

Why some young people seem to get worse on antidepressants instead of better is a matter of speculation and debate.

What is clear is that use of the drugs, called selective serotonin reuptake inhibitors or SSRIs, has surged in the United States in recent years. The FDA reports that doctors wrote 11 million prescriptions for SSRIs for teens and children in 2002.

In the wake of the FDA warning, some mental health providers fear a reversion to a time when childhood depression was not taken seriously.

“In my opinion, for kids really suffering from depression, the benefits of medication when used appropriately far outweigh the potential risks,” said Dr. David Fassler, a Vermont child psychiatrist who testified before the FDA for the American Psychiatric Association. “We can reduce symptoms of depression in 70 percent of kids using a combination of drugs and (other) therapy.”

Susan Buchanan, whose 17-year-old son has a history of mental problems, including depression, said the revelation about antidepressants reinforces her view that parents should not simply accept a doctor’s word that any given drug is safe.

“You really need to ask for whatever information they have so you can study it and see if it makes sense for your kid,” she said.

Still, the Roseville mother says she has seen the life-saving potential of antidepressants. Her son had been prescribed many different types of drugs over the years with various results. In June, after a spate of destructive rages, he threatened to hang himself. He was hospitalized, and after consulting with a new psychiatrist, started taking Celexa, one of the antidepressants targeted for a black-box label.

“He is calm now,” Buchanan said. “He is much more focused. He is doing well in school. This is the best he’s done in years.”

Some child psychiatrists are worried that primary care doctors, typically a youngster’s first medical contact, will refuse to prescribe an antidepressant if the label contains the black-box warning. With child psychiatrists already in short supply, it could be weeks before a child suffering depression can get in for an appointment. They say a gush of referrals -with no treatment in the interim weeks – could result in tragedy.

Dr. Thomas Newman, an epidemiologist and pediatrics professor at the University of California, San Francisco, and a member of the FDA’s pediatric committee, said he understands the psychiatrists’ concerns. But after reviewing the data, he said no one should prescribe antidepressants to children without fully understanding the risks and benefits.

“I think primary care doctors should be scared giving these drugs,” he said. “Messing with brain chemicals shouldn’t be done casually.”

Lorraine Slater agrees. Her 14-year-old daughter, Dominique, died in April 2003 after jumping into a canal. Slater blames her death on the four different antidepressants her daughter was put on in less than a year. She said the drug companies failed to warn of suicide risk and that Dominique’s doctors failed to carefully monitor her.

Dominique’s depression began during the summer of 2002. She told her parents she had taken an Internet survey sponsored by a drug company that seemed to confirm her depression and asked to see a doctor.

The family physician agreed Dominique was depressed and put her on an antidepressant. A month later, she tried to kill herself but failed.

A series of antidepressants and hospitalizations ensued. Finally, after being put on the drug Effexor, Dominique seemed happy. “I thought maybe the medication was working,” Slater said.

Days later, her daughter was dead.

“We were trying to treat her depression,” Slater said. “We weren’t given full disclosure. My responsibility was to care for her and nurture her, but the very thing I was doing to help her was the cause of her death.”

Dr. Richard Gorman, a Baltimore pediatrician who serves on the FDA’s pediatric advisory committee, said in the wake of the new warning, several parents have asked him to wean their children off antidepressants. Responding appropriately to the concerns will be key, he said. That means sorting out which kids are going through normal adolescent mood swings or bouts of anxiety and which are seriously ill.

“We would hate to see people who are benefiting be scared off by the risks,” he said. “But we would like to slow down the pen of the prescribing physicians looking for an easy way out.”

While few predict an end to antidepressant use in children, some mental health experts hope the FDA’s warning will create a shift in tactics, including more aggressive counseling for the child and family and more communication with the school.

“I think both psychiatrists and the rest of the mental health industry will be necessarily attempting to address children’s depression with non-pharmacological approaches,” said Dr. Lawrence Diller, a Walnut Creek behavioral and developmental pediatrician.

Most likely, more effort will be made to ensure children are properly evaluated and, if diagnosed with depression, referred for comprehensive treatment that may include counseling, medication and monitoring.

That will require health plans and state Medicaid programs to beef up coverage for mental health care, said Chuck Faltz, director of professional affairs at the California Psychological Association.

“The vast majority of children and adolescents being treated with antidepressants are probably not seeing a psychologist or social worker,” he said. “That is going to change. And it’s going to cost some money.”

About the Writer:  The Bee’s Dorsey Griffith can be reached at (916) 321-1089 or dgriffith@sacbee.com.